Open Journal Systems

EDUCATION

Received: February 11^th 2015

Accepted: March 4^th 2015

Burnout syndrome in medical residents at the General Hospital of Durango, México

Jovany Francisco Terrones-Rodríguez,^a Vicente Cisneros-Pérez,^b José de Jesús Arreola-Rocha^b

^aHospital General de Durango, Secretaría de Salud de Durango

^bDivisión de Estudios de Posgrado e Investigación, Facultad de Medicina y Nutrición, Universidad Juárez del Estado de Durango

Durango, México

Communication with: Vicente Cisneros-Pérez.

Telephone: (618) 130 1132

Email: vcisnerosp@gmail.com

Background: The burnout syndrome is commonly spread among health workers and students, due to the excessive demands they feel on their workspaces. Depersonalization, emotional exhaustion and personal accomplishment are the areas assessed.

Methods: To determine the prevalence of burnout syndrome in medical residents at the General Hospital of Durango; a descriptive, prolective, cross-sectional study was designed and applied to residents of different specialties of the General Hospital of Durango who agreed to participate, the “Maslach Burnout Inventory” was applied.

Results: We surveyed 116 residents, 43.1 % (50) women and 56.89 % (66) men. The overall prevalence was 89.66 % (95 % CI: 82.63- 94.54). Affected in a single area the 48.28 % (95 % CI: 38.90-57.74), in two areas the 35.34 % (95 % CI: 26.69-44.76) and in the three areas 6.03 % (95 % CI: 2.46-12.04). Stratified by areas, high emotional exhaustion was 41.38 % (95 % CI: 32.31-50.90), high depersonalization in 54.31 % (95 % CI: 44.81-63.59), and low personal accomplishment 41.38 % (95 % CI: 32.31-50.90).

Conclusions: The prevalence is higher than the reported. The most frequently affected is depersonalization, followed by emotional exhaustion and finally the personal accomplishment. In the areas of Gynecology and obstetrics, Internal medicine, Pediatrics and Orthopedics, the 100 % of the residents are affected.

Keywords: Burnout, professional; Working conditions; Physicians; Mexico

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Burnout syndrome is defined as the syndrome determined by chronic interpersonal conflict during labor practice. It is characterized by feelings of discouragement, depersonalization, and reduced self-efficacy, linked to fatigue and chronically demanding situations that are experienced as excessive in the workplace.¹

The psychological construct of burnout syndrome is primarily characterized by exhaustion, depersonalization, and cynicism, and by demotivation and dissatisfaction at work, leading to poor job performance; this emerges as a result of factors of prolonged stress, both in the emotional realm and in interpersonal relations at work.²

The development of the syndrome depends on the one hand on the worker's personality and on the other on the organization or institution where they work. Three areas are involved: reduction of personal fulfillment, emotional exhaustion, and depersonalization.³

It has been shown, generally, that the syndrome occurs in doctors regardless of gender. However, women are more vulnerable to developing this syndrome, as it coincides with studies indicating that they, primarily, are the ones who suffer from the double day, due to their involvement in the labor market (housework, family, and the social environment).

The Hospital General of the Servicios de Salud del Estado de Durango (SSD) often sees in the medical resident community apathy about the condition of the patients they treat, lack of attachment to their responsibilities as resident, decreased quality of participation and work that is part of their training, aggressive attitudes towards colleagues, and even quitting one’s specialization residency.

We also identify the declarations of the affiliated doctors who emphasize the poor performance that they see in their medical residents, as well as a lack of commitment to the service, to their patients, and to the hospital where they receive training, which is why we consider it necessary to know the prevalence of burnout syndrome in medical residents at Hospital General de Durango SSD.

Methods

Through an observational, descriptive, transversal, prolective study approved by the Research Ethics Committee of the Hospital General de Durango SSD, the questionnaire "Maslach Burnout Inventory" was applied to all resident doctors of the various specialties who agreed to participate and who were working actively at the Hospital General de Durango SSD. The instrument "Maslach Burnout Inventory" consists of 22 items presented for consideration by the interviewee on a 7-level Likert scale. Each item is a sentence in the form of statement that refers to the attitudes, emotions, or feelings that the individual shows in relation to their work or to their patients. Each item has seven response options, of which only one will be answered. Each response option in each of item is assigned a value of zero to six, with the score of each dimension of burnout being the sum of these values. According to the questionnaire the statements have been mixed to explore three dimensions: emotional exhaustion, depersonalization, and inefficiency or dissatisfaction with personal fulfillment, so that three subscales can be measured and differentiated representing the three factors or dimensions of the syndrome.

Results

There are 119 medical residents at Hospital General de Durango SSD. All were invited to participate in our study and only one of them did not accept. There were a total of 118 surveys, of which two were removed for being incomplete. The sample consisted of 116 medical residents in the specialties: anesthesiology 16 (13.7%), surgery 16 (13.7%), gynecology 23 (19.8%), internal medicine 9 (7.7%), family medicine 5 (4.3%), orthopedics 11 (9.4%), pathology 9 (7.7%), radiology 7 (6.0%), pediatrics 12 (10.3%), and emergency medicine 8 (6.8%).

Of the sample, 50 were women (43.1%) and 66 men (56.9%); of the total, 32 (27.59%) reported being married, 78 (67.24%) single, 5 (4.31%) cohabitating, and 1 (0.86%) separated. The ages of the participants ranged from 25 to 41 years. The average age is 29.09, standard deviation 2.70, variance 7.3, and mode 28.0. In their first year of residence there were 30 (25.86%), second year 39 (33.62%), third year 31 (26.72%), and fourth year 16 (13.79%).

Table I shows the overall prevalence of burnout syndrome at 89.66%, of which 58 (50%) were male and 46 (39.66%) female. It should be noted that the 58 men affected correspond to 87.88% (95% CI 77.51-94.62) of their gender, and the 46 women were 92% (95% CI 80.77-97.78) of their gender.

48.28% (95% CI 38.90-57.74) showed involvement of one of the areas, 35.34% (95% CI 26.69-44.76) two areas, and 6.03% (95% CI 2.46-12.04) three areas. Of the seven who had involvement of all three areas, two were in the surgery department, and one each in gynecology, internal medicine, orthopedics, radiology, and pediatrics.

Table II shows the stratified frequency of the three areas of burnout syndrome considering high, medium, and low for each, as well as the percentage and confidence interval.

Table III shows that in gynecology, internal medicine, orthopedics, and pediatrics, 100% of residents are affected.

In burnout syndrome with involvement in the area of emotional exhaustion, by specialty, gynecology had the highest number of cases with 12 (25%), followed by pediatrics with 8 (16.66%) (Table IV). By year of residency, 2^nd and 3^rd year residents represented the highest number with 14 cases each, followed by 1^st year with 11 cases, and finally 4^th year with 9 cases. As for percentage by specialty, 4^th year had the highest rate with 56.25%, followed by 3^rd year with 45.16%, first year with 36.67%, and finally second year with 35.90%. With regard to marital status, single people were the most affected with 43.59%, followed by married people with 40.63%. Cohabiting individuals accounted for 20%. By gender, women have the highest frequency with 22 (44%) affected, and men with 26 (39.39%) affected.

When analyzing burnout syndrome with involvement in the area of depersonalization, by specialty, gynecology had the highest frequency with 14 (22.22%) cases, followed by pediatrics and orthopedics with 8 (12.69%) (Table V). By year of residence, 3^rd year had 64.52%, followed by 4th year with 56.25%, then 1^st year with 50%, and finally 2^nd year with 48.72%. By marital status, single people had 44 (56.41%), followed by married people with 17 (53.12%) and subsequently cohabitating and separated people with 1 case (20%). By gender, 37 men were affected (56.06%) and 26 women (52%).

As for burnout syndrome with involvement in the area of personal fulfillment, surgery has the highest number of cases with 11 (22.91%) and percentage by specialty with 68.75% (Table VI). By year of specialty, by percentage the greatest affectation was observed in 1^st and 4th year with 50% respectively, followed by 3^rd year with 45.16%, and in last place by affectation 2nd year with 28.21%. In terms of marital status, the highest number of cases was found in single people with 36 (46.15%), married people with 9 (28.13%), cohabiting with 2 (40%) and separated with 1 (100%). By gender, 29 men were affected (43.94%) and 19 women (38%).

Discussion

Burnout syndrome is an increasingly prevalent problem among health professionals, which affects the performance, quality, and safety of patient care. The "Maslach Burnout Inventory" is the instrument validated in Spanish with the greatest acceptance of its measures. It is the most widely used in different studies evaluating involvement of an occupational nature.

The study we have done is really interesting and allows us to see how the syndrome affects a large population of resident doctors at the Hospital General de Durango SSD, some in only one of the areas, and in others, two or even all three areas. We found no studies with the same characteristics in the medical literature, where the sample was residents of all specialties in a particular health institution. The studies found focused on a specific specialty or on a population different from ours.

We found the prevalence of burnout syndrome in residents of different specialties higher than that reported by Molina et al., who reported a prevalence of 69.2% (95% CI 62.1-75.4) when studying a group of doctors and pediatricians.⁴

The entire population of residents in gynecology, internal medicine, orthopedics, and pediatrics is affected, followed by surgery and emergency medicine residents with a lower percentage. The family medicine specialty was the least affected. When comparing our results, we note that there is agreement with the study by Alvarez-Hernandez et al. in which they determined the prevalence of burnout syndrome in pediatric residents at Hospital Infantil del Estado de Sonora, finding that 100% (n=58) of residents showed burnout syndrome.³

Of the three areas that make up burnout syndrome, depersonalization was where the greatest involvement was observed in the entire resident population, followed by emotional exhaustion, and finally personal fulfillment; Guido De Azevedo et al., when studying the presence of burnout syndrome among multidisciplinary residents at the Universidade Federal de Santa Maria in Rio Grande do Sul in Brazil found that 65% of medical residents had high emotional exhaustion; 61.7% high depersonalization, and 30% low professional accomplishment,⁵ the first two areas being reversed with respect to our study.

In each of these, only in the area of emotional exhaustion, women accounted for the highest percentage of affectation, since in the other two, men remained at the highest levels. Singles always represented the largest number of people affected in all areas, consistent with most studies in other populations. With regard to gender, our study differs with that reported in the literature, where women are noted as the most vulnerable population, because of their social roles and the situation of the double workday. Hernandez-Gracia et al. in his article: "Burnout syndrome: an approach to its conceptualization, history, and explanatory and measurement models," notes that burnout syndrome mainly affects women because of the diversity of professional and family tasks, which affects their job performance. With regard to marital status, the greatest impact is seen in single people.⁶

By stratifying each of the areas, we note that in emotional exhaustion, gynecology residents make up the majority of people affected, followed by pediatrics residents and subsequently orthopedics and surgery; however, we must take into account that there are specialties where the number of residents is significantly higher than in others, which greatly influences the results. When taking proportional calculations, we note that pediatrics tops the list of those affected, followed by orthopedics and then radiology and gynecology. Family medicine is the specialty where we find the lowest level of affectation.

Focusing on the year of the specialty, second and third year residents represent the largest population affected, although in percentage terms, fourth year residents are the most committed in this area, with 56.25%, followed by third year with 45.16%; women have the highest percentage. By marital status, singles have the greatest impact from burnout syndrome in this area, followed by married people. People cohabitating showed a very low level of affectation.

Speaking of affectation in the area of depersonalization, gynecology remains the most predominant. Proportionally, orthopedic residents are the most affected, followed closely by radiology residents. Again family medicine is in the lower levels. Second and third year residents represent the largest number of people affected, as in the area of ​​emotional exhaustion, but in percentage terms, now the third-year residents lead the level of affectation, followed by fourth year. Here men are most affected and also single people remain predominant. We only had one resident with the marital status separated, who was also affected.

In the area of ​​personal fulfillment, data are somewhat different to the previous ones. The highest frequency of the residents in the affected population and proportionately are those in general surgery. Internal medicine is the specialty with the lowest number affected. Residents of the second year are the most affected in both frequency and percentage, and men are above women in the level of affectation in this area. Single people again are more affected relative to others.

The results from our study are consistent with those of the literature, determining that, of the three areas that make up burnout syndrome, emotional exhaustion and depersonalization are the two with the greatest impact. Hernandez et al. in their article Burnout syndrome in Mexican doctors, mention that emotional exhaustion and depersonalization form what they call the heart of burnout.⁷

Analyzing burnout syndrome with affectation in different areas, we note that the greatest percentage is residents impacted in a single area. Then there are residents with involvement in two areas and finally, those with all three areas affected are a small but significant population, and one that we must observe carefully; of the latter, there are two general surgery residents affected, and one resident affected in each of gynecology, internal medicine, orthopedics, radiology, and pediatrics. In this group of residents we must employ professional care measures to prevent progress to improper and critical conduct or action by those affected, knowing that this is the population that needs the most therapeutic support.

Suffering from burnout syndrome may be accompanied by some degree of depression. Trejo-Lucero et al., studying nurses who work in a High Specialty Hospital, identified the association of burnout syndrome with depression, finding that this association exists and that high scores of the syndrome are associated with serious depression.⁸

It is necessary to do screening tests, since, as mentioned by various authors, the importance of detecting patients with depression, and in this case with incipient depressive symptoms, lies in the effectiveness of early treatment. Within the clinical signs of burnout syndrome, Carrillo-Esper et al. in their article "Burnout Syndrome in Medical Practice", note that there are manifestations of psychiatric illness with progressive deterioration, such as depression and chronic anxiety, mood disorders, suicide, serious family dysfunction (violence), and addictions (including addiction to work). The recognition of burnout syndrome and depression is key in general practice, because if these disorders are not detected or recognized, they cannot be treated.⁹

This study at the Hospital General de Durango SSD is only the beginning. Knowing the prevalence of burnout syndrome in medical residents is a big step, which will serve as the basis for new studies to expand knowledge, and then prevention and treatment strategies can be implemented to help us reduce the number of cases per year and to treat those already identified by our study, all with the aim of training excellent professionals, improving health care, and growing health institutions.

We must not forget that human beings are essentially social beings, who seek a balance in the different areas of life such as family, religion, friends, and work, so one must attempt to strike a balance in these areas.

It is essential to carry out diagnostic tests for burnout syndrome once a year after learning the prevalence we have detected, tracking the cases found, and monitoring their behavior using prevention and treatment strategies. To do this, it is important to promote athletic activities or exercise that will improve their personal motivation and drive performance; at the same time to help to alleviate stressful situations that arise in the inpatient setting. Allowing spaces for recreation and life with family and friends, highlighting the importance of their work as doctors, letting them know that their efforts are recognized, and encouraging them to continue their training. Promoting interpersonal relationships among co-workers, while highlighting solidarity and mutual support, makes the demands of work and inflexible schedules of medical residency less burdensome. Rest areas between working hours allow physical and mental rest for increased performance. Work plans attached to reality, leaving aside unfeasible projects that, far from being finished, wrap us in a feeling of anxiety and frustration when they cannot be completed; this also without falling into complacency or monotony.

It is then vitally important to have specialists (psychologists and / or psychiatrists) performing psychotherapeutic interventions in found cases of burnout syndrome, helping them to do their hospital work with better adaptation, applying jointly the preventive measures already mentioned to avoid relapse.

Conclusions

The detected prevalence of burnout syndrome is above that reported in other studies conducted in health workers. The area of burnout with the most cases affected was depersonalization, followed by emotional exhaustion and finally personal fulfillment.

100% of the populations of residents of the gynecology and obstetrics, internal medicine, pediatrics, and orthopedics specialties are affected, which should be grounds for review. Men are the most affected, except in the area of ​​emotional exhaustion, where women had a greater degree of involvement. With regard to marital status, singles are the population most affected. Among those married and cohabiting, the latter are the least affected by burnout syndrome.

We detected seven cases with involvement in all three areas of burnout syndrome, which requires immediate attention by qualified personnel.

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